The Affordable Care Act, commonly known as Obama Care, has injected huge amounts of funding into the healthcare system for the poor. Organisations as divergent as Denver Health, a government run group and the University of Pittsburgh Medical Centre (UPMC), a strictly private affair, have found common ground and greater capacity in their responses to disadvantaged, high need patients courtesy of these reforms. American healthcare is rapidly evolving!
In the case of Denver, the Intensive Outpatient Care model is focused on patients who typically have a mental health diagnosis alongside their other chronic diseases. They often identify these patients whilst in hospital and make bedside visits to invite participation. Patients are groomed to access 24 hour help lines amongst other intensive case management supports. Patients enrolled in this service typically have a two hour first visit to ensure an accurate patient history is taken. This history addresses all of the social determinants of health alongside physical and psychological indicators. Their primary care team includes addictions counselors, psychiatrists, exercise physiologists, pharmacists, psychologists, social workers, patient navigators, nurses and a doctor. Notably, both the nurses and medics on this team have a reduced patient load to accommodate the additional complexity of their patient group. Once the patient’s health and environment has improved they are gradually moved into medical homes with a less intensive but nonetheless comprehensive service.
In the UPMC model they have one doctor and one nurse practitioner serving just 116 patients with support from other nursing and healthcare resources. They have modeled their response on emerging data which is showing that high needs patients in groups of up to 200 are economically supported by one doctor and multiple nurses each supporting around 30 patients. Depending upon the mix of patients, some nurses may be performing at nurse practitioner level, others as chronic disease specialists. Still other team members perform health navigation and care coordination activities across the internal and external players involved with the patient.
These models are very patient centred. It is common for many visits to occur in homes with nurses leading the interaction and establishing tele-health contact with primary care doctors as required. This ensures that the home environment and family members are also included in the support and care team. Reducing barriers to health improvement is fundamental in these models. Both sites talked about the importance of providing funding for webster packing of drugs and subsidies for accessing drugs. They even went to the extent of providing free mobile phones and bus passes to assist patients step up their involvement in their own care. In both cases the results have been dramatic improvements in health profiles, huge reductions in presentations to emergency and marked savings in hospital admissions.
Success has generated shared savings which have returned to the primary health provider. Denver is now proposing to use these funds to branch into a program focused on the children of those with long-term mental illness. Such targeted care, will encompass school and social inputs as well as health provision and be coordinated by the primary healthcare team.
We have long looked at the American health system as one which fails the poor. Based on current trends, it will emerge as a world leader in programs for the disadvantaged and multi-morbid patient in the next five years. In Australia, we have a universal healthcare system designed to serve the typical patient. Too often, and in increasing numbers, we are not seeing typical patients. We too need to move into models of care which are patient centred and comprehensive. These high need patients will then receive the support they really require and the health system will achieve savings which can be plowed back into further innovation.
Tracey Johnson, General Manager, Inala Primary Care